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Map: Where States Stand on Medicaid Expansion Decisions

*Map updated July 24, 2015

This map tracks state Medicaid expansion decisions and approaches states are taking for expanding eligibility to 138 percent of the Federal Poverty Level (FPL). This map also includes information on 2015 and 2014 state legislative activity around Medicaid expansion {1}, the Governor’s stance on the issue, and fiscal and demographic analyses from the state or other institutions. For states that are expanding Medicaid, but using an alternative to traditional expansion, the map also contains brief descriptions of these demonstration waivers.

Like all State Refor(u)m research, this map is a collaborative effort with you, the user. State Refor(u)m captures the health reform comments, documents, and links submitted by health policy thinkers and doers all over the country. And our team periodically supplements, analyzes, and compiles this key content.

Know of something we should add to this compilation? Your feedback is central to our ongoing, real-time analytical process, so tell us in a comment, or email acardwell@nashp.org.

On 7/16/15, Governor Walker announced plans to expand Medicaid using executive authority; eligible individuals may be able to begin enrolling in September

In February 2015, the Governor of Alaska and the Department of Health & Social Services released a Medicaid expansion and reform plan, The Healthy Alaska Plan. The plan proposes to expand Medicaid to adults with incomes up to 138% FPL and outlines how Medicaid expansion functions as the catalyst for meaningful reform in the state's existing Medicaid program. The Governor plans to evaluate potential strategies for increasing prevention and shared responsibility, through cost sharing requirements, health savings accounts, incentives for healthy behavior and work assistance benefits.

There were two special sessions held, but Medicaid expansion was not advanced by legislators and the budget included language restricting the executive branch's authority to expand Medicaid; however some legal analyses indicate that this budget provision is not constitutional

SB 78 and HB 148 supporting expansion, submitted by request of the Governor; FMAP must be no less than 90%

Alaska House Finance committee, acting as the subcommittee on the Department of Health and Social Services, removed Medicaid expansion from the department's budget on February 27, 2015.

Alternative to traditional expansion: Arkansas is expanding Medicaid through an 1115 waiver, the Arkansas Health Care Independence Program, which has been approved by CMS through 12/31/16, with eligibility effective 1/1/14. The waiver allows the state to implement Medicaid expansion through a premium assistance model by using federal Medicaid funds to purchase coverage through qualified health plans (QHPs).

The plan covers all newly eligible individuals ages 19 to 64, including parents between 17-138% FPL and childless adults between 0-138% FPL (medically frail individuals are exempt). While no premiums are required, there is cost sharing for enrollees between 100-138% FPL that must be consistent with Medicaid and QHP rules.

In August 2014, the state provided public notice of its intent to submit a written request to CMS to amend the Health Care Independence 1115 waiver. The proposed amendments include the following: (1) Independence Accounts for individuals with incomes above 50% FPL, (2) cost-sharing for individuals with incomes from 50-100% FPL, and (3) changes to the state's non-emergency medical transportation (NEMT) benefit for individuals participating in the Demonstration. In December 2014, CMS approved the waiver amendment.

Florida state lawmakers returned for a special session on June 1; in advance of the session, SB 2A was filed; it is identical to SB 7044, with some exceptions noted here; the special session ended June 19, without passage of expansion

SB 7044 both expands Medicaid and establishes a state health insurance exchange through the Florida Health Insurance Affordability Exchange Program

Alternative to traditional expansion: In January 2015, CMS approved Indiana's waiver for the Healthy Indiana Plan 2.0 (HIP 2.0), which expands on the state's existing Healthy Indiana Plan (HIP). HIP 2.0 expands coverage to non-disabled individuals ages 19-64 up to 138% FPL, with coverage beginning 2/1/15. HIP 2.0 permits the state to collect premiums through contributions to Personal Wellness and Responsibility (POWER) accounts. Individual contributions cannot exceed 2% of household income and are also funded with state contributions.

HIP 2.0 offers two levels of benefits, HIP Basic or HIP Plus. Individuals in HIP Plus will have access to additional benefits, with the only copayments being for non-emergency use of the emergency room, which is a required copayment for all HIP 2.0 enrollees. All individuals who contribute to POWER accounts will be enrolled in HIP Plus. HIP Basic has more limited benefits and has copayments allowed under existing Medicaid rules.

For individuals above 100% FPL, contributions to POWER accounts are required as a condition of eligibility. If they stop contributing, after a grace period they will be disenrolled and not permitted to reenroll for six months, unless they meet certain exceptions. Individuals below 100% FPL can participate in either HIP Plus or HIP Basic, but for these individuals, contributions to POWER accounts are not a requirement for coverage. If they are in HIP Plus but then cease to contribute, they will be automatically enrolled in HIP Basic.

The waiver exempts the state from providing NEMT in the first year and the state can encourage employment through a separate program, but there is no work requirement. The waiver runs through 1/31/18 and offers premium assistance for individuals w/ESI.

In July 2015, Iowa released a draft waiver amendment for public comment that proposes to end enrollment of individuals above 100% FPL in the Marketplace Choice Plan due to a lack of plan issuers; these individuals will instead be enrolled in Medicaid managed care plans in 2016

Alternative to traditional expansion: Iowa is expanding Medicaid through the Iowa Health and Wellness Plan, which required two 1115 waivers, the Iowa Marketplace Choice Plan and the Iowa Wellness Plan. Both waivers were approved by CMS through 12/31/16, with eligibility effective 1/1/14. The Iowa Marketplace Choice Plan allows the state to implement Medicaid expansion through a premium assistance model by using federal Medicaid funds to purchase coverage through qualified health plans (QHPs) for newly eligible individuals ages 19-64 who have incomes 101-138% FPL (medically frail individuals are exempt).

The Wellness Plan provides Medicaid coverage through a medical home model for individuals ages 19-64 with incomes from 0-100% FPL and medically frail individuals up to 138% FPL.

Both plans have premiums based on income level beginning in the second year of the demonstration, while cost sharing cannot exceed 5% of the beneficiary's annual income. The premiums can be reduced or waived if certain healthy behavior standards are met. Also, there are copayments for non-emergency use of the emergency room, and non-emergency medical transportation (NEMT) will not be a covered service for individuals under either waiver. Iowa submitted a waiver amendment to request to continue waiving NEMT service for members under the Iowa Health and Wellness plan who are not medically exempt.

Alternative to traditional expansion: Michigan is expanding Medicaid through an 1115 waiver, the Healthy Michigan program, which has been approved by CMS through 12/31/18 and is effective 4/1/14. The Healthy Michigan program expands Medicaid coverage to individuals ages 19-64 with incomes up to 138% FPL, and beneficiaries will participate in health savings accounts that can be used for required cost sharing payments.

Total annual cost sharing cannot exceed 5% of the beneficiary's annual income, and cost sharing can be reduced if individuals participate in certain healthy behaviors and preventive care measures. Beneficiaries with incomes above 100% FPL will also make premium contributions, not to exceed 2% of an individual's annual income.

In March 2015, Governor Nixon revised his thoughts on a proposed Medicaid expansion plan. In the governor's plan, all adult Medicaid recipients would be referred to a career center, those who refuse to work would face higher premiums and copays and could lose coverage, and beneficiaries would be charged for improper use of the emergency room. The plan would also include incentives to quit smoking.

In April 2014, the governor announced Missouri Health Works proposal which directs federal Medicaid dollars to small businesses to subsidize part of the cost of health insurance for employees that are paid less than 138% FPL

SB 419 to expand Medicaid under a block grant through the creation of the "Healthcare Transformation Trust Fund."

HB 1901 supporting expansion through a Premium Assistance model with maximum cost sharing and premiums of 1% of income for all enrollees and a workforce requirement for most individuals. Adults under 100% FPL would be covered through Medicaid managed care plans.

Alternative to traditional expansion: On April 29, 2015, Governor Bullock signed SB 405, the Montana Health and Economic Livelihood Partnership Act (HELP Act), which expands the state's Medicaid program through an 1115 Waiver. The HELP Act requires enrollees to pay the maximum copayment amounts allowed under federal law, and excludes copayments on preventive services, generic drugs, immunizations, and other medically necessary healthcare screenings. Additionally, enrollees are required to pay premiums of 2% of their monthly income. Enrollees above 100% FPL who fail to pay premiums within 90 days of notification of the overdue payment, may be disenrolled in coverage unless they meet specific criteria such as participation in a workforce program or following a healthy behavior plan. The HELP Act also authorizes and appropriates funds to implement a new voluntary workforce development program for enrollees.

In July 2015, Montana's Department of Public Health and Human Services (DPHHS) posted a draft waiver application for public comment; further information is available at DPHHS' page on the HELP Act.

Supports; a Medicaid expansion proposal, the Healthy Montana Plan, is included in the proposed 2017 biennium budget; plan is modeled after state's CHIP program and would contract with an insurer to provide healthcare through a private provider network at negotiated rates

SB 405 supporting expansion through the Montana Health and Economic Livelihood Partnership Act (HELP Act); signed by the governor on 4/29

HB 455 supporting expansion only for parents up to 100% FPL and some veterans

Alternative to traditional expansion: New Hampshire passed legislation (SB 413) approving Medicaid expansion, signed into law on March 27, 2014. Under the proposal, the state sought a federal waiver for a premium assistance model of coverage, the Health Protection Program, which was approved in March 2015. Prior to this federal approval, eligible individuals were enrolled on July 1, 2014, with coverage beginning on August 15, 2014 in New Hampshire's Medicaid managed care program. With waiver approval, the state will transition these individuals in 2016 to the Health Protection Program. Also, some individuals who are eligible for an existing program to subsidize employer-based coverage, the Health Insurance Premium Payment program, will receive coverage through that program. The Health Protection Program also includes a work referral component, and expires on December 31, 2018.

On May 30, 2014, the New Hampshire Department of Health and Human Services submitted a waiver to CMS to support reform of the state's Medicaid program and overall delivery system; the waiver for the Health Protection Program was submitted in November 2014; this premium assistance waiver was approved on 3/4/15.

On February 9, 2015, Governor Wolf announced that the state will be transitioning to a traditional Medicaid expansion plan. In March 2015, the governor announced a timeline for a two phased transition process that is set to begin in April 2015 and conclude in September 2015.

Alternative to traditional expansion: Pennsylvania will expand Medicaid through an 1115 waiver, with coverage beginning on January 1, 2015. While the original waiver proposed expanding Medicaid through a premium assistance model by using federal Medicaid funds to purchase coverage through qualified health plans, the approved version provides Medicaid coverage to newly eligible adults through contracts with private managed care organizations. The plan will cover all newly eligible individuals ages 21-64 from 0-138% FPL (medically frail individuals are exempt).

The plan includes premiums (beginning in January 2016) on a sliding income scale beginning at 100% FPL, with the opportunity for reduced premiums if individuals participate in certain healthy behavior activities. The other form of cost sharing would be for non-emergency use of the emergency room. The state will not offer non-emergency medical transportation during the first year of the demonstration but will provide this service to beneficiaries beginning in year two (January 1, 2016).

Supports a version of expansion; in December 2014, Governor Haslam announced a proposed expansion plan, the Insure Tennessee Plan, which would have provided coverage to individuals ages 21 to 64 with incomes up to 138% FPL. The proposed plan was intended to be a two-year pilot program that required approval from both the state legislature and federal officials, but in February 2015, the Tennessee Senate Health and Welfare Committee voted against Insure Tennessee. Individuals would have chosen to participate in either the Volunteer Plan or the Healthy Incentives Plan.

The Volunteer Plan would have provided individuals with a health insurance voucher to use to cover costs such as premiums and out-of-pocket expenses in an individual's employer-sponsored health insurance plan. The voucher program would have provided a fixed contribution amount, and the individual would have had to pay any costs that exceeded the amount.

Individuals that would have chosen to participate in the Healthy Incentives Plan would have received coverage through a component of the TennCare program. They would have participated in Healthy Incentives for Tennessee (HIT) accounts, and individuals would have received contributions into their HIT accounts by participation in healthy behaviors. Funds from these accounts would have been used to pay for cost sharing expenses. Individuals with income above 100% FPL would have had to pay both premiums and copayments, and all enrollees would have had pharmacy copayments.

In addition to the federal match, the Insure Tennessee Plan would have been funded through a partnership with state hospitals, which would have covered the state's portion of the cost once the FMAP decreases below 100%.

SJR 93 supporting expansion through a proposal based on Governor Haslsam’s Insure Tennessee plan. Three new elements include a lockout provision for enrollees failing to pay premiums, delaying implementation of the program until the U.S. Supreme Court rules on King vs. Burwell, and receiving written confirmation from CMS that TN can opt out if state tax money is ever required for the program. The bill was defeated in the Senate Commerce Committee in April 2015, less than a week after it was initially passed by the Senate Health and Welfare Committee.

In January 2015, Governor Haslam called for a special legislative session beginning on February 2, 2015 to consider the Insure Tennessee Plan. On February 4, 2015, the Tennessee Senate Health and Welfare Committee voted against Insure Tennessee.

SB 885/HB 1018 proposes to repeal the existing requirement that the legislature must approve expansion

SJR 105 allows the governor to take all necessary action to expand Medicaid

SJR 94 allows the governor to take certain actions related to Insure Tennessee

Against; in November 2014 the Texas Institute of Health Care Quality and Efficiency recommended that the state health commissioner should be authorized to negotiate with the federal government to expand health coverage

In December 2014 Governor Herbert released further details about the Healthy Utah Plan. The plan, which still needs state legislative and federal approval, expands Medicaid for adults ages 19-64 with incomes up to 138% FPL primarily through a premium assistance model. For most enrollees the plan uses federal Medicaid funds to purchase qualified health plan (QHP) coverage through Avenue H, the state's health insurance marketplace for small businesses. Medically frail individuals have the choice to enroll in Healthy Utah or receive traditional Medicaid benefits. Eligible adults with access to employer-sponsored insurance will enroll in those plans with Medicaid providing premium assistance, cost sharing and wrap-around coverage.

The plan proposes premiums for individuals with income above 100% FPL and has copayments for certain services for all enrollees. In the second and third year the plan would provide incentives for participants to complete certain healthy behaviors. Certain unemployed individuals will be enrolled in an integrated work program, which will include job search and training services, and currently the state is exploring options to maximize program participation. The plan would terminate if federal funding drops below the ACA's enhanced Medicaid match rate.

HCR 12 resolution passed stating governor, lieutenant governor, and legislative leaders will find a compromise to the Healthy Utah Plan by July 31, 2015. If an agreement is reached, the governor will call a special legislative session to vote on the plan.

On July 17, 2015, state officials indicated that they have agreed on a conceptual framework for Medicaid expansion; a formal proposal may be ready for lawmakers to vote on by September

The Governor of Wyoming and the state's Department of Health released a Medicaid expansion plan, the Strategy for Health, Access, Responsibility, and Employment (SHARE) plan to expand Medicaid to adults with incomes up to 138% FPL. The plan, which still needs approval by the state legislature and federal officials, imposes co-payments for certain services on all enrollees, while individuals with incomes above 100% FPL would pay premiums ranging from $20 to $50 per month. Enrollees who complete certain healthy behaviors could reduce premiums in the following year. Program participants would be enrolled in a work assistance benefit at the time of application, including job search and training services, but the use of these services would not be a condition of eligibility. The expansion program would terminate if federal funding drops below the 90% match for these new adults.

SF 129 supporting expansion; aligns with Governor's SHARE plan; on February 6, 2015, the Wyoming Senate voted against the bill

In December 2014 the Joint Labor, Health and Social Services Interim Committee endorsed a draft Medicaid expansion bill that differs from the plan proposed by the state's Department of Health, and includes a proposal for individuals to contribute to personal health and wellness accounts.

Amendment in budget bill allowing the Governor and other executive branch departments to negotiate with the federal government about a Medicaid expansion waiver

SF 118 supporting expansion through a Premium Assistance model with premiums not exceeding 2% of annual income for individuals with at or below 100% FPL; FMAP must comply with ACA and non disabled individuals will enroll in health savings accounts

Key:

states (count includes the District of Columbia) are expanding Medicaid

states are expanding Medicaid, but using an alternative to traditional expansion

1 state is expanding Medicaid; pending federal waiver approval

1 state is transitioning from an alternative Medicaid expansion to traditional expansion

{1} This map provides a record of legislation introduced, but does not track the exact status of bills moving in state legislatures. Map is updated when bills pass chambers and/or are signed by the Governor.

{2} CMS approved WI's proposal to modify existing Medicaid eligibility; under the waiver, all childless adults ages 19-64 with income up to 100% FPL will be covered through BadgerCare Plus beginning 4/1/14.

Related categories:

Topics:

Type of Expansion

Traditional: State is implementing Medicaid expansion as outlined in the ACA

Alternative to traditional expansion: State is using a demonstration waiver to expand Medicaid

N/A: State is not expanding Medicaid at this time

Governor's Stance on Expansion

Indicates whether the current Governor is against or supportive of Medicaid expansion

2015 Legislative Activity

View bills introduced in 2015 related to expansion.

2014 Legislative Activity

View bills introduced in 2014 related to expansion.

Fiscal and Demographic Analyses

Includes state-specific analyses related to Medicaid expansion, conducted directly by a government agency, contracted out by the state to another institution, or conducted by organizations or institutions independent of the state.

Comments

Hi Anita, this was really informative. I am trying to get some information around IES, basically which state has planned to integrate the eligibility systems etc. Can you please guide me on any such resource.

Donna,
Thanks for your comment. You can now download a pdf version of the map--under the gray box to the right of the map you will now see an option to download the map as a pdf; the pdf version will include the key and the footnotes.

Ginny,
We're glad you found the map helpful. You can use the map in your presentation; we would just ask that you please credit State Refor(u)m as the source. You can download either an image or a pdf version of the map--this option is available under the gray box to the right of the map.

Robert Smith posses a very important question: Medicaid Waivers are at risk of being lost by non-expanding states like Texas and Florida. Texas stands to loose in excess of $3.5 Billion dollars in Medicaid waivers. It is hard to tell how many consumers these funds serve, but a quick analysis of marketplace coverage suggests 700,000 individuals can be insured in the healthcare Marketplace with those same funds (benchmark Silver, HMO, $0 Deductible; $1.5K Max OOP). Meanwhile Texas just filed an amicus brief in support of Florida's surprising turn around against medicaid expansion and the risk of loosing Medicaid waivers.